Meaghan Kiley February 27, 2014

NURS 627
Case Study #13

Cardiovascular disorders can be extremely debilitating to individuals and are
often linked to other comorbidities. Certainly, factors such as diet, exercise, smoking, and
age can contribute to how cardiovascular disease is controlled and managed. K.Z. is a 58-
year-old male with significant cardiac history, hypertension, chronic renal insufficiency,
coronary artery disease, and suffered from an anterior wall myocardial infarction one
year ago. He is a current smoker with a 50-pack-year smoking history. In addition, he
has experienced occasional episodes of heart failure, and was recently diagnosed with a
4-cm suprarenal abdominal aortic aneurysm.
Due to his cardiac health, he is scheduled for a same-day cardiac catheterization
and requires education about the procedure along with discharge instructions. Upon
gathering K.Z.s past medical history, it is important to note this individual has many
additional stressors in his life besides his medical condition including the death of his
wife (around the same time he had his MI) and is about six months into retirement from
his job as a railroad engineer after physical limitations have made it difficult for him to
continue his career.
Before sending K.Z. to the catheterization laboratory, it is important to explain the
purpose of the procedure. The data that the cardiac catheterization will produce will be
addressed, explaining that it will yield both anatomic and hemodynamic data. The
physical structure of the heart can be visualized; oxygen saturation can be determined,
and defining K.Z.s cardiac output will help further evaluate the patency of the coronary
arteries, the hearts efficiency, and its ability to circulate blood through the chambers
(Tremko, 1997). A small catheter will be inserted to either a femoral or brachial vessel
and threaded to the left or right side of the heart. The contrast medium will identify any
coronary artery narrowing or occlusion, or coronary blockage (ATI, 2013).
Priority topics regarding patient safety will be addressed to help prepare K.Z for
the procedure. K.Z. will be told he must remain NPO (no food/drink by mouth) for eight
to 12 hours before the procedure. This order will reduce the risk of aspiration intra-
procedure and the contrast medium may cause nausea and vomiting. K.Z.s allergies are
vital to address because the contrast medium used for the procedure is contraindicated to
individuals who have an iodine or shellfish allergy. Proper preparation such as
administering Benadryl before the procedure can prevent any complications. Conscious
sedation is used so the patient will become relaxed, typically IV midazolam (Versed) is
the drug of choice (Tremko, 1997). Conscious sedation means the patient will be awake
but sedated during the procedure, but therefore he may feel warmth and flushed when the
dye is injected. The affected extremity must be kept straight postoperatively and K.Z.
should know to immediately report any bleeding from the insertion site, chest pain,
shortness of breath, and change of color and/or temperature of the extremity (ATI, 2013).
Based on K.Z.s past history, there are many factors that could contribute to his
risk for cardiac ischemia. Although ischemia can be reversible, K.Z. already has
myocardial damage due to his anterior wall MI one year ago. However, K.Z. has many
existing risk factors that continue to categorize him as a risk for cardiovascular damage.
Factors that may contribute to K.Z.s risk for cardiac ischemia include: gender (male),
hypertension, smoking, stress (occupational, death of spouse), and advancing age. The
case study lacks information about K.Z.s diet and physical activity, but older adults who
are physically inactive with a chronic disease, such as hypertension, and have poor
lifestyle habits, such as smoking, are at increased risk for coronary artery disease. Based
on past medical history, it is known that K.Z. has already been diagnosed with coronary
artery disease. In addition, the incidence of cardiac disease increases with age and
predispose the heart to poor blood perfusion and oxygen delivery. Lifestyle modification
should definitely be a priority for K.Z. and should include smoking cessation,
maintaining physically active, consuming a diet low in saturated fats and sodium, and
continue to have cholesterol and blood pressures checked regularly. A diet such as the
DASH diet, which is high in fruits, vegetables, and low-fat dairy foods, but is low in high
sodium and fat, would be preferable for K.Z. Medication compliance and lifestyle
modification (diet, exercise, stress reduction) should go hand in hand to best reduce the
risk of further cardiac damage (ATI, 2013).
The results of K.Z.s cardiac catheterization reveal the following results: 90%
occlusion of the proximal left anterior descending coronary artery, 90% occlusion of the
distal LAD, 70% to 80% occlusion of the distal right coronary artery, an old apical
infarct, and an ejection fraction of 37%. About one hour after the procedure was
finished, assessment reveals a grade III/VI systolic ejection murmur at the cardiac apex,
crackles bilaterally in the lung bases, and trace pitting edema of his feet and ankles.
Except for the systolic murmur, these findings were not present before the
catheterization.

An ejection fraction of 37% is significant to K.Zs heart status. The ejection
fraction is a representation of how much blood the left ventricle pumps out with each
contraction. Therefore, an ejection fraction of 37 percent means that 37 percent of the
total amount of blood in the left ventricle is pushed out with each heartbeat. A normal
hearts ejection fraction is usually between 55 and 70. K.Z.s exceptionally reduced
ejection fraction is indicative of heart failure, and more specifically, systolic heart failure
(left-sided). In heart failure, the heart muscle does not contract effectively and less
oxygen-rich blood is pumped out to the body (American Heart Association, 2014). Due
to the extent of occlusion both on the right side and left side of the heart, K.Z. most likely
has right and left-sided heart failure. Physical assessment reveals symptoms of right-sided
heart failure including peripheral edema (edema in feet and ankles) and left-sided heart
failure including the low ejection fraction and pulmonary systemic congestion
represented by bilateral crackles in the bases of the lungs (ATI, 2013).
The result of the cardiac catheterization and degree of blockage of the coronary
arteries also confirms K.Z.s diagnosis of coronary artery disease (CAD). CAD is
characterized by the accumulation of fatty deposits along the inner layer of the coronary
arteries. When the walls of the arteries thicken, it can narrow the arteries and decrease or
block the flow of blood to the heart (Massachusetts General Hospital, 2014).
Based on the physical assessment, K.Z. requires interventions regarding heart
failure. To increase and promote maximum ventilation, K.Z. should be positioned in
high-Fowlers (90 degrees) and oxygen should be administered if necessary. Due to the
accumulation of fluid, there should be a restricted fluid intake along with a restricted
sodium intake. This intervention will help decrease any additional fluid retention. A
diuretic should be administered intravenously to reduce preload and help correct edema
and hypertension. If Lasix is administered, the patients electrolytes should be closely
monitored and he should be encouraged to ingest foods high in potassium to prevent
hypokalemia. Due to crackles bilaterally and heart murmur; K.Z. should be assessed for
pulmonary edema. Monitor the patient for a persistent cough with pink, frothy sputum,
tachycardia, dyspnea, and low urine output; all signs symbolic of pulmonary edema (ATI,
2013).
After assessing K.Z., the physician admits him with a diagnosis of CAD and HF
for CABG surgery. Significant laboratory results drawn at this time are Hct 25.3%, Hgb
8.8 g/dL, BUN 33 mg/dL, and creatinine 3.1 mg/dL. K.Z. is given furosemide (Lasix) and
2 units of packed RBCs (PRBCs).

These laboratory values of kidney function, hemoglobin and hematocrit, are
indicative of chronic renal insufficiency and anemia. Due to the poor perfusion of K.Z.s
heart, it can be assumed that the cause of his chronic renal insufficiency is poor perfusion
to the kidneys. The extra fluid in heart failure places additional stress on the kidneys,
making it more difficult for the kidneys to function properly. After analyzing his
laboratory values and cardiac history, it seems his chronic renal insufficiency is
secondary to heart failure. In conjunction with renal insufficiency, the kidneys produce
erythropoietin, a hormone that stimulates the bone marrow to produce an adequate
amount of red blood cells needed to carry oxygen to vital organs. Kidneys that are
unhealthy lack erythropoietin, ultimately causing anemia, or low red blood cells
(National Kidney and Urologic Diseases Information Clearinghouse, 2013).
In effort to correct K.Z.s anemia, he received 2 units of packed red blood cells.
Packed red blood cells are typically used for treatment of symptomatic anemia, especially
with low hemoglobin. Packed red blood cells are also preferred over whole blood because
there is less danger for fluid overload. In K.Z.s situation, fluid intake needs to be
carefully monitored because he has already presented signs of fluid overload.
Administering Lasix, a loop diuretic, in combination with packed red blood cells, will
help flush the kidneys and prevent the accumulation of excess fluids.
Five days later, after his condition is stabilized, K.Z. is taken to surgery for a
three-vessel coronary artery bypass graft (CABG x3V). When he arrives in the surgical
intensive care unit, he has a Swan-Ganz catheter in place for hemodynamic monitoring
and is intubated. He is put on a ventilator at FiO2 0.70 and positive end-expiratory
pressure (PEEP) at 5 cm H2O. His latest hemoglobin is 10.3 mg/dL. You review his first
hemodynamic readings and arterial blood gases.
Hemodynamic Readings
Pulmonary artery pressure (PAP) 38/23 mm Hg
Central venous pressure (CVP) 16 mm Hg
Pulmonary capillary wedge pressure
(PCWP)
18 mm Hg
Cardiac Index (CI) 1.88 L/min/mm2
Arterial Blood Gases
pH 7.37
PaCO2 46 mm Hg
PaO2 61 mm Hg
SaO2 85%

Assessment of K.Z.s arterial blood gases reveals that K.Z. has an acid- base
imbalance and is in respiratory acidosis. It is evident that the acid-base imbalance is of
respiratory origin because K.Z.s carbon dioxide (PaCO2) is outside of the expected
range. In addition, K.Z. has poor oxygenation status, which suggests increased carbon
dioxide. Acidosis is determined because the pH is less than 7.40, but is still in the
expected reference range that also explains that the acid-base imbalance is fully
compensated. Based on the arterial blood gas values, it is possible that K.Z. is having
difficulty perfusing blood to the capillaries due to pulmonary edema.
In K.Z.s situation, it would be inappropriate to use pulse oximetry to assess
K.Z.s oxygenation status because he has anemia. Individuals, who are anemic, may have
a lack of functioning hemoglobin in the blood to oxygenate the tissues. However, the
small amount of functioning hemoglobin that does exist in those who are anemic may be
well saturated with oxygen. Therefore, it is possible K.Z. may have a normal pulse
oximetry reading, but a lack of oxygen going to the tissues. Ultimately, pulse oximetry in
anemic patients is unreliable and a poor indicator of true oxygenation status (Philips,
2014).
K.Z.s hemodynamic status is most likely being monitored because of his
decreased cardiac output. By measuring different pressures in his heart, a better
understanding of his hearts status can be obtained. K.Z.s central venous pressure (CVP),
which is a measure of blood volume and venous return is used to monitor fluid volume
status, and is extremely elevated. An increased CVP, which is presented, can be
indicative of fluid overload and vasoconstriction. He may require diuresis and
vasodilation to ultimately decrease afterload. Pulmonary hypertension is also revealed by
K.Z.s pulmonary artery pressure, meaning it is difficult for the heart to pump blood to
the lungs. Pulmonary artery wedge pressure (PCWP), measures pressures generated by
the left ventricle and assesses left ventricular function. In K.Z.s case, his PCWP is
elevated representative of left ventricular failure. Cardiac index reflects the hearts ability
to meet the bodys oxygen demands and takes into consideration an individuals body
size. K.Z.s cardiac index is low, revealing that the supply doesnt meet the demand
(Hemodynamic Monitoring, 2014).
In hopes to improve K.Z.s cardiac function, K.Z. is receiving continuous IV
infusion of nitroprusside and dobutamine as pharmacological interventions. Nitroprusside
is being administered to K.Z. because nitroprusside, provides rapid and pronounced
venous and arterial vasodilation at usual dosages (Coons, 2011). Although nitroprusside
will benefit K.Z., the administration of nitroprusside requires invasive monitoring or
blood pressure. Slow weaning to discontinuation is advised because of the potential for
rebound vasoconstriction (Coons, 2011). Dobutamine has both inotropic and
vasodilatory effects, to promote an increase in cardiac output. In addition to aiding the
heart in contraction, dobutamine promotes a decrease in pulmonary capillary wedge
pressure. In addition to its positive effects on the heart, dobutamine intravenously works
rapidly, within one to two minutes (Coons, 2011). After the administration of
dobutamine, it is essential to monitor for hypotension and irregular heart patterns, such as
atrial fibrillation, adverse effects of this inotropic drug.
After 3 days in the SICU, K.Z.s condition is stable, and he is returned to your
telemetry floor. Now, 5 days later, he is ready to go home, and you are preparing him for
discharge. List four general areas related to his CABG surgery in which he should
receive instruction before he goes home.

K.Z. received a CABG (coronary artery bypass grafting) procedure in effort to
restore vascularization of the myocardium, or heart muscle. Before returning home, K.Z.
should receive education regarding his incision, which includes sternal precautions.
When coughing or deep breathing, K.Z. should splint his incision with a pillow to prevent
complications. In addition, he should be instructed to monitor and report any signs of
infection (fever, drainage, and redness) at the incision site. Physical activity after CABG
should be resumed slowly. For a client like K.Z., a cardiac rehabilitation program should
be encouraged. Participating in a weekly cardiac rehabilitation program will promote
monitored exercise so the client can return to activity safely. K.Z. should remain home
during the first week of recovery and slowly resume his normal activities. Although K.Z.
is now retired, it is recommended that patients possibly return to work part-time and
increase social activity during the second week of recovery. During week 3 of recovery,
K.Z. should lift no more than 15 pounds and avoid heavier lifting for additional 6 to 8
weeks. Once K.Z. reports walking the equivalent of one block or climbing two flights of
stairs without symptoms, he can continue to gradually increase physical activity (ATI,
2013).
In effort to overall improve his health, referral to a smoking cessation program
would also be helpful for K.Z. Once he has resumed normal physical activity, he should
develop a weekly exercise routine in combination with a heart- healthy diet. Although
K.Z. already has myocardial damage, lifestyle modifications can decrease future risk for
additional cardiac events.










References
ATI: RN Adult Medical Surgical Edition. 2013. Edition 9.0

Coons, J., McGraw, M., & Murali, S. (2011). Pharmacotherapy for acute heart failure
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doi:10.2146/ajhp100202
Ejection Fraction Heart Failure Measurement. (n.d.). American Heart Association.
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Measurement_UCM_306339_Article.jsp#
Hemodynamic Monitoring Study Questions. (n.d.). Hemodynamic Monitoring. Retrieved
February 25, 2014, from
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Massachusetts General Hospital. (n.d.). Coronary Heart Disease. Retrieved February 26,
2014, from http://www.massgeneral.org/conditions/condition.aspx?id=116

National Kidney and Urologic Disease Information Clearing House (NKUDIC). (2013,
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http://kidney.niddk/nih.gov/kudiseases/pubs/anemia


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